​October ​28, 2015

Pulse on ​Family Medicine: Primary Care Policy Update

New Graduate Entry Program: More Questions
than Answers?

The New Graduate Entry Program was launched by the Ministry of Health and Long-Term Care (MOHLTC) on October 23 through an INFOBulletin, and is receiving swift and vocal feedback from family physicians about potential detrimental impacts to comprehensive family medicine and very importantly, impacts on communities.

The program, as described, limits new graduates from being compensated for anything outside of the office in the first year and imposes caps in years two and three. The limits appear to include payments for such things as practicing obstetrics, covering ER shifts in community hospitals and providing after hours home visits for palliative care.  The OCFP has received questions from members asking for clarity about the New Graduate Entry Program and shared these concerns directly with the MOHLTC.

The MOHLTC’s push continues to be for new family physicians to establish practices in underserved areas of the province. In fairness, the MOHLTC recognized that limiting new graduates from practicing in the team-based models in which they are trained was an unintended consequence of managed entry into only high-needs areas. Launching the New Graduate Entry Program (NGEP) is intended to open up access to team-based models of practice (FHO/FHN) for new family physicians in areas that are not designated as high need by the ​Ministry. 

The catch? There are ‘prices of entry’ including phased salary, limits on fee for service payments, and parameters around rosters.  There are also stipulations about mentoring, and quality improvement performance targets. The concept of supporting new graduates to establish their practices over a period of time, and to practice a high standard of quality care is well intentioned. Unfortunately, some of the parameters in the program as currently released may have significant unintended consequences to health-care delivery in communities across Ontario, particularly in rural and mid-size communities.  

In-office comprehensive services

  • It appears that the only payment provided under the NGEP in the first year is for in-office comprehensive services. It is unclear whether services like obstetrical deliveries, ER shifts, in-hospital or community palliative care, as well as other hospital services would receive payment. The NGEP is not clear about supporting new family physicians with ​Certificates of ​Added ​Competency who may work either full-time or part-time and do palliative care, anaesthesia or emergency medicine for non-rostered patients in their communities. What does this mean for comprehensive family practice in communities that rely on family physicians for these services? How does this facilitate the integration of graduates who complete Certificates of Added Competency into communities where they wish to also have a comprehensive family practice?
  • The MOHLTC plan for family medicine and primary care in Ontario needs to be clarified. The first year in practice is crucial for consolidating the skills acquired in ​family ​medicine training. It is unlikely that a new graduate who does not do things like obstetrical services or ER shifts in the first year of practice will still have the confidence to provide these skills later in their career. In addition, if skills are not practiced and maintained, it will be challenging for hospitals to grant privileges for those services even if a physician was willing to provide them. If the Ministry of Health wants to support communities to have fully skilled comprehensive care family physicians providing full services after entering practice, including for obstetrics, palliative care and ER coverage, how can that be better supported?

Patient rosters and succession planning

  • The Ministry has an appropriate focus on ensuring that all Ontarians have a family physician and the focus of the NGEP is to have new graduates enrol previously unattached patients.With that focus, the NGEP stipulates that a new graduate cannot enrol a patient previously rostered to a family physician in their existing FHO/FHN. Many family physicians, in non-high needs areas, are approaching retirement and would support a new graduate to gradually transition their practice. It has already been identified by the MOHLTC that access to FHO positions in the managed entry system for retirements are still on a 1:1 basis (except for rosters over 2,400 patients). It does not seem possible under this NGEP to split an existing roster to slowly manage transition during the first three years of practice. How does the NGEP align with the managed entry for high needs areas and being able to take over an existing practice in a way that is appropriate and manageable for a new grad?
Performance Targets
  • New graduates entering non-high needs areas in a FHO or FHN will have to meet or exceed performance criteria.The performance targets are not yet clearly identified. Additionally, new graduates will be expected to sign up to receive a primary care practice report. If a new physician will not have performance data for at least a year, how will the metrics be staggered over the three-year NGEP window?
  • For an existing FHO or FHN that is not part of a Family Health Team, there may be limited experience with quality improvement plans and targets. Currently, physicians in practice do not have specific targets to maintain in order to receive funding, and so there appears to be a different standard for new graduates in the NEGP. What is the obligation for FHO and FHN leads to coach and mentor around quality improvement targets for new grads? After year three, when the new graduate becomes a full member of the FHO/FHN will they still have performance targets that will be different than the expectation of the other FHO/FHN family physicians?
  • Patient experience surveys may promote the delivery of patient-driven choice rather than best practices. New graduates may feel pressure to keep patients “happy” in order score well, and as a result may drive utilization, rather than focus on more appropriate testing and treatment (i.e. Choosing Wisely recommendations). What is the metric for patient experience surveys? What role will the MOHLTC and Health Quality Ontario have in patient education around best practices, which may mean not getting access to unnecessary medications or diagnostic tests?

Mentoring

  • For existing FHO/FHN family physicians who accept new graduates, there is an expectation of mentoring.What is the obligation around mentoring these new graduates? This may be part of academic Family Health Teams, but how will non-FHT FHOs and FHNs establish formal mentoring programs or understand the expectations for mentoring?
  • For new FHO’s comprised of all new graduates, there is an expectation that an external FHO or FHN physician would provide mentorship. For these new graduates, how will they be supported to find mentors outside of their practice? Similarly, what is the accountability for these mentors for the new graduates?
Family physicians recognize the challenges in primary care and health system affordability and sustainability. We are advocating for family physicians to be part of developing solutions that truly support the delivery of high-quality, coordinated, comprehensive and continuing care by family physicians for all Ontarians. We must also advocate for our bright, capable young graduates who will be the future of ​family ​medicine in this province. They need to be supported to provide care to their fullest ability, especially in the first few years of practice.

Patient advocates have long stated in health-care planning and decision-making that there is “​nothing about us, without us”. This is a time for family physicians to adopt this principle.